DOCUMENTATION & REIMBURSEMENT

IN OCCUPATIONAL THERAPY
 OBJECTIVES

• Review basic components of effective documentation

• Explore different types of occupational therapy
documentation
• Learn how reimbursement is linked to documentation
 WHAT IS GOOD
DOCUMENTATION?
 THE SIX C S

1. Chronological record
2. Comply with reimbursement
3. Communicate
4. Clinical reasoning
5. Collect data
6. Courtroom defense
 DOCUMENTATION BEST PRACTICES

• Be timely with your documentation

• Avoid jargon
• Check for accuracy, grammar, readability
• Be ethical
• Reflect the individual client
• Show the value of occupational therapy
TYPES OF DOCUMENTATION
 EVALUATION

• Critical piece of documentation

• Occupational profile
• Measurements
• Assessments
• Summary of findings
• Justification for OT (if OT is needed)
 INTERVENTION PLAN

• Client background information (demographics, precautions, etc.)

• Goals
• Intervention approaches
• Service delivery
• Frequency, duration
• Tentative plan for discharge
• Outcome measures
• Signature
 DAILY NOTE

• Client background information – who was the service provided to?

• What happened during the OT visit?
• Interventions provided
• Justification
• Client response
• What are the associated codes for billing?
• Missed visits
 PROGRESS NOTE

• Client background information

• Summary of services during the progress note period
• Description of client’s current occupational performance
• Plan or recommendations
 DISCHARGE NOTE

• Client background information

• Summary of client’s intervention process
• Progress toward goals
• Current occupational performance
• Recommendations
 ADDITIONAL NOTE TYPES

• Screening note
• Transition plan
 QUALITY REPORTING

• Merit-based Incentive Payment System (MIPS)

• Outpatient OT

• IMPACT
• Sub-acute settings
REIMBURSEMENT
 TERMINOLOGY

• Charge: how much you bill for a service

• Reimbursement: how much you get paid for a service
• Allowable charge
• Cost: the financial expenditure associated with providing the service
 PAYMENT SOURCES

• Private pay
• Payment through insurance
• Commercial insurance
• Federal insurance
• Grants/charity
 PRIVATE PAY

• Client pays for service

• Only sustainable in certain demographic areas
 INSURANCE

COMMERCIAL FEDERAL
• HMOs, PPOs • Medicare
• Aetna, Anthem, Cigna, etc. • Inpatient: Part A
• Workers’ compensation • Outpatient: Part B
• Often managed by third-party • Medicaid
administrators (Sedgwick, Gallagher Bassett,
Align, etc.) • CHIP
• IDEA
• VA
 GRANTS & CHARITY FUNDING

• Seek out grants to cover services that aren’t reimbursed by insurance

companies
 HOW CAN PAYMENT BE MADE?

• Per time period

• Per beneficiary or recipient
• Per episode
• Per day
• Per service
• Per $ of cost
• Per $ in charges

Reimbursement is different than charges!

BILLING FOR OT SERVICES
 CPT CODES

• Current Procedural Terminology = CPT codes

• Used to bill for services
Numeric Code Written Code Description
97165 Occupational therapy evaluation, Clinical decision making of low complexity, usually 30
low complexity minutes spent face to face
97166 Occupational therapy evaluation, Clinical decision making of moderate complexity, usually
moderate complexity 45 minutes spent face to face
97167 Occupational therapy evaluation, Clinical decision making of high complexity, usually 60
high complexity minutes spent face to face

97168 Occupational therapy re-evaluation Includes assessment of changes in patient functional or

medical status with revised plan of care
Numeric Code Written Code Description
97530 Therapeutic activity Use of dynamic activities to improve functional
performance. Examples of such activities include lifting,
pushing, pulling, reaching, throwing, etc.
97110 Therapeutic exercise Therapeutic exercises to develop strength, endurance,
range of motion and flexibility
97112 Neuromuscular re-education Neuromuscular reeducation of movement, balance,
coordination, kinesthetic sense, posture, and/or
proprioception for sitting and/or standing activities
97140 Manual therapy techniques Manual therapy techniques (e.g.,
mobilization/manipulation, manual lymphatic drainage,
manual traction), 1 or more regions
 BILLING FOR TIME-BASED CPT CODES

8-MINUTE RULE RULE OF 8 S

• Medicare / federal payors • Most commercial insurance
• Mixed remainders okay • Have to bill 8 minutes of each individual
unit
• Looks at total treatment time
• Need to bill 23 minutes of the same unit
8 – 22 minutes 1 unit to bill a second unit for that code
23 – 37 minutes 2 units • Ex) 10 mins TA + 10 mins TE + 8 mins
38 – 52 minutes 3 units NM = 28 minutes. Can bill 3 units (1 TA,
1 TE, and 1 NM)
53 – 67 minutes 4 units
• Ex) 10 mins TA + 10 mins TE + 8 mins
NM = 28 minutes. Can bill 2 units (1 TA
and 1 TE)
ADVOCATING FOR OT SERVICES
 ADVOCACY IN ACTION

• Legislation surrounding billing & provision of care does

change from time to time
• Stay up to date and get involved!

• OT has its own “pot” of Medicare $

• OT can now open home health cases
• OTs can still make orthoses
 REFERENCES

• Jacobs, K., McCormack, G. L., & A., P. K. J. (2019). The occupational therapy
manager. AOTA Press.